| NPI | 1063917631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: VA 0101276325) |
| Additional Taxonomies | 208600000X Surgery (Licence: WA MD61586721) |
| Enumeration Date | 2018-03-27 |
| Last Update Date | 2025-09-24 |